Clerkship Templates

The Clerkship Templates section provides soap note templates for different clerkship during the 3rd, 4th year of Medical School, and Residency. Prepare and Learn Ahead! Educating and providing resources to students interested in the medical field.

General SOAP Template

• Subjective:
  • Chief complaint
  • History of present illness (OLDCARTS)
  • Pertinent review of systems
  • Pertinent past medical history, family history, lifestyle, social factors
• Objective:
  • Vital signs: Temp, HR, respiratory rate, BP, spO2 
  • Targeted physical exam findings (pertinent negative and positive findings)
  • Medications and allergies
  • Labs/diagnostic tests that have already been completed
• Assessment:
  • Differential diagnosis (usually in most likely order with probable etiologies)
• Plan:
  • Plan of treatment for each diagnosis

DOWNLOAD General Soap Note Template (Clerkship Templates)

DOWNLOAD General Soap Note Template (Clerkship Templates)

DOWNLOAD Soap Note Simple Template

DOWNLOAD New Patient Soap note – 2 Patients

Emergency Medicine SOAP Note

• Chief complaint
• Identifying data
• Subjective:
  • HPI
  • PMH/PSH
  • Allergies
  • Meds
  • SocHx
  • Family history
  • ROS (ok to have pertinent positives and negatives, followed by the statement “all other
    systems were reviewed and were negative)
• Objective:
  • Vital signs: Temp, HR, respiratory rate, BP, spO2 
  • PE (only need to include detail where it is pertinent. In general, it is a good idea not to
    say things like “nonfocal”, “normal”, or “within normal limits”.
    • For example, if you have a patient with abdominal pain and you did not do a full neuro exam but the patient
      seems grossly intact, don’t say “grossly intact”. Include specifics such as “Alert and oriented x3. Pupils equal. Normal gait.”
• Assessment:
  • define the acute problem (e.g. This is a 66 yo male with a history of CAD presenting with stuttering CP of 3 days duration.)
  • list a differential diagnosis (need not be very broad)
  • pick your one or two most likely diagnoses and support why you think these are
    likely
• Plan:
  • tests ordered
  • specific plans if the key tests are positive or negative
    • (for example, we will do an ECG and if he is having a STEMI, call a STEMI alert, if there are no ECG changes,
      we will order a troponin)
  • if the plan includes discharge, need to plan for follow up.
• Test results:
• Reassessment note:
  • After the results were back, what decision did you make regarding patient disposition?
    • Admit?
    • Discharge and follow up?
    • ALL ED patients should get follow up with someone.
  • This part of the note can be narrative and will vary greatly depending on the patient.

Pediatric SOAP Note

• Date and Time of H&P: 
• Historian: The history was obtained from both the patient’s mother, who is considered to be a reliable historian.
• Chief complaint: 
• Subjective:
  • History of Present Illness:
  • ROS:
    • CONSTITUTIONAL: No fever, weight loss. Mother reported increased irritability.
    • EYES: Seems to have difficulty focusing at distances
    • EARS, NOSE, MOUTH/THROAT: No otorrhea, no congestion.
    • CARDIOVASCULAR: No history of heart murmur, no cyanosis.
    • PULMONARY: No cough or increased work of breathing, but mom did notice that he  occasionally breathes fast then stops for a few seconds, then starts up again. It’s most  noticeable when he sleeps.
    • GI: Mom says patient passes a lot of gas. When he was breast-fed, he had a soft stool after every feed – sometimes 8-10 a day. He only had two stools in the last 24 hours. His umbilical cord fell off three days ago.
    • GU: patient displays a strong stream of urine when he voids.
    • NEUROLOGICAL: Patient was very shaky after birth but that’s slowly resolved.
    • MUSCULOSKELETAL: No edema or trauma
    • HEMATOLOGY: No ecchymosis or bleeding.
    • DERMATOLOGY: see HPI
  • Birth History:
    • Weeks gestation
    • NSVD or C-section
    • First prenatal visit
    • Mother’s Prenatal screen, Diagnosis, Treatment
    • Birth weight and length
    • Complications at delivery
    • APGAR score
    • Length of hospital stay
    • Require any respiratory support or phototherapy while in the nursery.
    • Newborn screen, results 
  • Past Medical History: No past medical history to date. Mother denies any accidents and injuries. Mother has not established her pediatrician and patient did not receive his two-week well-child check-up.
  • Past Surgical History: Circumcision, no complications
  • Immunizations: Hepatitis B vaccine was given in the nursery.
  • Medications: No medications
  • Allergies: No known allergies
  • Family History:
    • Paternal Grandfather – Unknown
    • Paternal Grandmother – Unknown
    • Maternal Grandmother – Healthy with no known medical problems
    • Maternal Grandfather – Unknown
    • Mother – Healthy with no known medical problems
    • Father – Unknown
    • Siblings
    • There is no family history of diabetes, seizures, cancer, heart disease, hypertension or sickle cell  on the maternal side. However, very little is known about the paternal side.
  • Social History:
    • Lives with
    • Parents level of education, work 
    • Pets: Their residence contains no pets.
    • Smoking: No one in the home smokes.
    • Diet: Patient was breast-fed exclusively until one day prior to admission. Since then he has received Similac, 3-4 oz. every 3-4 hours. He receives occasional water.
    • Development: Mother has bonded with her son taking the main responsibility of care and feeding. Patient is able to hold his head up off the bed when prone. He cannot roll over and he smiles but not socially.
• Objective:
  • Vitals: Temp 37.8 rectal Pulse 156 Respiratory Rate 45 BP 86/47 SpO2 98% on room air
  • Physical Exam:
    • Growth parameters: Weight 3.41 kg (10-25%ile) Height 54 cm (50%ile) Head Circumference 37.5cm (50%ile)
    • General: Patient is a well-developed, well-nourished infant in no apparent distress. Patient is asleep but easily arousable. Appears well hydrated.
    • Head: Normocephalic, atraumatic with thick hair. Anterior fontanelle measures 1×1 cm, is soft and flat with normal pulsations. Posterior fontanelle is fingertip. Sutures show mild molding with a remnant of a small right parietal cephalohematoma.
    • Eyes: Pupils equal, round and reactive to light. Extraocular muscles appear intact but patient too young to cooperate with exam. No discharge, conjunctivitis or scleral icterus. No ptosis. Patient focuses briefly on face. Fundi-unable to visualize. Positive red reflexes bilaterally.
    • Ears: Clear external auditory canals. Pinnae normal is shape and contour. No pre-auricular pits or skin tags. TM’s grey bilaterally. No erythema or bulging.
    • Nose: Normal pink mucosa, no discharge or blood visible. Normal midline septum.
    • Mouth: moist mucous membranes, small 1mm white papule on posterior roof of mouth c/w Epstein’s Pearl. No evidence of a cleft on palpation of roof.
    • Pharynx: Unable to visualize tonsils. Pharynx shows no erythema or ulcerations. Normal movement of soft palate.
    • Neck: Grossly non-swollen. No tracheal deviation. No decrease in ROM. No lymphadenopathy, goiter or masses detected.
    • Chest: Tanner II breast development – palpable nodule below bilateral areolae. Round chest cavity. No increase of accessory muscles – no evidence of increased work of breathing. Lungs are clear to auscultation bilaterally. No stridor, wheezes, crackles, or rubs. Good air movement.
    • CV: Quiet precordium, no right ventricular heave, no thrills. PMI in left mid-clavicular line in 6th intercostal space. Regular rate and rhythm. Normal S1 with normally split S2 on respiration. No murmurs, gallops or rubs. 2+ pulses in all extremities including strong bilateral femoral pulses. Capillary refill less than 2 sec.
    • Abdomen: Soft, non-tender, non-distended. Bowel signs present. Liver edge palpable 1 cm below costal margin but scratch test reveals normal liver size of 5 cm. No noted splenomegaly. No masses. Umbilicus healing well – no erythema, discharge or foul smell; mild diastasis recti present.
    • Genitalia: Circumcised; normally placed urethral meatus. Bilaterally descended testes measuring 1.5cm bilaterally, GU Tanner I, Pubic Hair Tanner I; no hernias, no hydroceles.
    • Extremities: Warm, no clubbing, cyanosis or edema. No gross deformities. Good skin turgor with no tenting. Negative Barlow and Ortolani signs – no hip clunks.
    • Back: straight, no lordosis, no kyphosis. Symmetrical Gallant reflex present. No sacral dimple, no hair tuft.
    • Skin: Vesicular lesions filled with whitish-yellow fluid covering the lower abdomen, inguinal region and upper thighs. The largest lesions measure 2mm by 3mm in size. Nikolsky sign – negative. Several small pea-sized nodes palpable in both inguinal regions. Positive Mongolian spot (slate gray patch) about 5 cm in diameter on sacrum.
      • Neurological: Moves all extremities symmetrically, appropriate tone.
        CN I deferred
        CN II can focus on face briefly, PERRL
        CN III, IV, VII unable to tell if eyes move in all directions
        CN V corneal reflex deferred
        CN VII symmetrical facial expression, closes eyes forcefully
        CN VIII startles to clap
        CN VII, IX, X, XII positive gag, symmetrical soft palate movement, normal swallow and cry
        CN XI deferred
        Normal symmetrical moro, gallant reflexes. Normal asymmetric tonic neck reflex. Normal
        stepping reflex. Symmetrical biceps and patellar DTR’s, upward going plantar reflexes, 2-3 beat
        clonus both feet. Negative Brudzinski and Kernig signs.
  • Labs: (Date and Time all labs)
    • CBC w/ differential: WBC 12.7 (N 29%, L 59%, M 9%, E 3%, B 1%), Hgb 15.9, Hct 47.5, Plts 458, RBC 4.39, RDW 14.7
    • CMP: Na 137, K 5.2, Cl 103, bicarb 23, BUN 6, Cr 0.5, Glu 102, Ca 10.6, Total Protein 6, Albumin 3.3, Total bilirubin 0.7, ALT 7, AST 30
    • Urinalysis: (Date and Time) Collected by catheterization. Negative for bacteria, leukocyte esterase, nitrite, WBC and RBC
    • CSF (Date and Time) Glucose 49, Protein 161 (H), WBC 3, RBC 28,565 (H), No organisms seen on gram stain
    • Blood and urine cultures are pending.
    • Diagnostic Imaging:
    • CXR (Date and Time) Preliminary findings are negative. Official reading pending.
• Differential:
  • Causes include: 
  • Discussion: 
  • They should be kept for consideration if other more common causes are ruled-out.
• Assessment:
  • Patient is a 2-week-old term, previously healthy male infant with acute onset of a localized, vesicular diaper rash and associated irritability. The most likely causes of his rash include herpes simplex, Staph scalded skin syndrome (SSSS), and bullous impetigo based on his history and physical exam findings.
• Plan:
  1. Vesicular rash possibly due to HSV, SSSS, or bullous impetigo; worsening – At this time the etiology of patient’s rash is unclear, but since the differential diagnosis contains lifethreating conditions he needs to be evaluated and treated for these causes. He has received a full sepsis workup, including: CBC with differential, blood culture, UA and urine culture by catheterization, CXR, CMP, and CSF analysis (including cell count, protein, glucose, gram stain and bacterial culture, and PCR for HSV). Additionally, we will also obtain a sample of the vesicular fluid to send for: gram stain, bacterial culture, viral culture, and HSV PCR. He should also receive HSV viral culture swabs of the eyes and mouth. He should be started on appropriate antimicrobial therapy while we are awaiting culture and PCR results. He will be placed on acyclovir 20mg/kg/dose q8h IV to cover for HSV, cefotaxime 150mg/kg/day divided q8h IV (or ceftazidime) to cover for GBS and E. coli (which are common pathogens for neonatal sepsis), and vancomycin 15mg/kg/dose q12h IV to cover for Staph aureus. Contact isolation precautions for potential HSV and Staph aureus. We will monitor patient closely with vital signs q4h and reassess if he starts to worsen.
  2. Irritability is likely related to discomfort from his rash and seems to be improving. We will monitor him carefully, and provide comfort measures. If he appears to be in pain, he may receive acetaminophen.
  3. Elevated protein and RBC count in CSF – This is most likely related to a traumatic tap, rather than meningitis, since he had no increase in WBCs in the CSF nor any signs of meningitis on exam (although these may be difficult to assess in neonates). If he deteriorates, we will consider repeating the LP to obtain further diagnostic information, such as repeat HSV PCR.
  4. Vomiting; Fluids, Electrolytes, Nutrition (FEN) – The infant’s vomiting has now resolved and he is tolerating PO fluids well. However, because he is being placed on both acyclovir and vancomycin, we will start IV fluids to maintain hydration and prevent acute kidney injury. We will order the patient’s home formula ad lib and will consult lactation as mother wishes to re-establish breastfeeding. We will monitor daily weights and strict Is and Os.
  5. Health Maintenance – We will obtain the results of patient’s newborn screen and help his mother establish a pediatrician for follow up.
  6. Social – Consult medical social work to help with TennCare insurance issues.
• Disposition:
  • Patient requires inpatient care due to need for further diagnostic workup, IV antibitoics, and IV hydration.

Download Pediatric Newborn Template

Progress Note

The progress note for inpatient services—surgery, medicine, psychiatry, OB/GYN, and pediatrics. 

• DATE and TIME every note in the left hand margin
• MS3 – MS4 Note
• Subjective: Pt slept well overnight, awaking twice with a productive cough. Pt states pain control is OK with PCA. No further n/v/d. No SOA, cp. Pt requests “regular food” today.
• Objective:
  • Vitals: Tmax 100.5 Tcurrent 98.4 BP 110/65 P 72 RR 18 O2 Sat 94% on 1L n/c
  • I &O = 2350/2000 = -350cc
  • Physical Exam:
    • Gen: Elderly male in NAD, alert
    • HEENT: PERRL, EOMI, no palpable nodes or thyromegaly
    • CV: RRR with a 2/6 soft systolic murmur heard best at the RSB. Cap refill < 3 sec
    • Pulm: Some soft rhonchi bilaterally, improved. No wheezes.
    • Abd: S/NT/ND/+BS
    • Ext: 2+ pitting edema in ankles bilaterally extending to mid-calf. No clubbing, cyanosis.
  • Lab: CBC, BMP pending this AM
  • Imaging: CXR pending this AM
• Assessment/Plan:
  1. 70 yo male with COPD exacerbation, HD #4, doing well.
     1. Continue to titrate O2, continue Levaquin and Solu-Medrol,
     2. continue albuterol breathing treatments PRN.
  2. EtOH dependence
     1. No signs of withdrawal at this time.
     2. Will use Ativan PRN for tremor or seizure.
  3. Chronic leg pn
     1. Will attempt to D/C PCA today and start on Neurontin.
  4. D/C planning
     1. Social work to see pt this AM.
     2. Will f/u at resident clinic.
• Margin: list medications in the left margin. Note which ones are scheduled and which are prn. State how many days the patient has been on each antibiotic (i.e. vancomycin day #4)

Admission Orders

ADC VAN DISSEL

1. Admit:
   1. Floor, team, house officer, attending, etc.
   2. For instance, admit to 46C ICU, Med I Service, Dr. Myles MD., Beeper #1234
2. Diagnosis:
   1. The diagnosis may be specific
      1. for example acute appendicitis, or may be asymptomatic diagnosis if a specific diagnosis is not yet known, for instance, abdominal pain.
   2. For postoperative orders, include the surgical procedure which was performed, for instance, appendectomy.
   3. Always include under diagnosis the patient’s allergies or lack of known allergies, for instance NKDA or allergic to penicillin.
3. Condition:
   1. The patient’s condition on admission, transfer, or post-operatively is noted here as stable, critical, etc.
4. Vitals:
   1. Temperature, blood pressure, pulse, and respirations of the patient.
   2. Other specific monitoring, such as weight, CVP, PCWP, CO, neurologic signs, etc. should also be listed here.
      1. For instance, Vitals: Q1hr., daily weights, Swan-Ganz measurements Q shift.
5. Activity:
   1. This describes the activities allowed for the patient
   2. For instance, up ad lib, bed rest, bathroom privileges, bedside commode, ambulate TID, up in chair QID, limited visitation, etc.
6. Allergies:
   1. List any drug allergies, and what reaction accompanies each (i.e. rash).
7. Nursing procedures:
   1. Bed position: For instance, elevate HOB 30 degrees, Trendelenburg position, etc.
   2. Preps: This generally refers to preoperative patients and includes, for instance, bowel preps, surgical preps, showers, etc.
   3. Dressing changes and wound care.
   4. Respiratory care: Although respiratory care is generally provided by Respiratory Therapy rather than nursing, Respiratory Therapy orders that do not include medications are often included here, for instance, PD&C (percussion and postural drainage), TC&DB (turn cough and deep breathe), incentive spirometry, nasotracheal suctioning, etc.
   5. Notify house officer if: This establishes parameters in vital signs beyond which nursing will notify the patient’s resident for further orders, for instance, notify HO for temp 38, systolic BP 90, PCWP 20, etc.
8. Diet:
   1. NPO, regular, mechanical soft, clear liquid, 1600 cal ADA, 2 gm sodium restriction, tube feedings, protein restricted, etc.
9. Intake and output:
   1. This includes the frequency with which nursing will monitor and record I&O as well as any tubes, drains, or lines the patient might have, for instance:
      1. Record hourly I&O
      2. NG tube to low intermittent suction
      3. Foley catheter to dependent drainage
      4. Hemovac, surgical drains, chest tubes
      5. Endotracheal tubes, arterial lines, central venous lines
10. Specific drugs:
    1. This includes all medications to be given on a specific schedule, for instance:
       1. Antibiotics, diuretics, cardiovascular drugs, etc.
       2. Also include allergies to medications.
       3. IV orders include simply the type of IV solution and the rate at which it is to be infused, for instance, D5 1/2NS
          TRA 50 cc/hr.
       4. When the patient has both central and peripheral lines, these are specified separately, for example, D5 1/2NS TRA TKO via peripheral line and D5 1/2NS TRA 100 cc/hr via central line.
       5. Inpatient medication orders are written with the name of the drug, dosage, route of administration, and frequency of administration specified, for instance, Digoxin 0.125 mg PO Qday.
11. Symptomatic drugs:
    1. This includes all drugs to be given on a pm basis
    2. For instance, pain meds, laxatives, sedatives, etc.
12. Extras:
    1. This includes any diagnostic procedures to be performed, for instance, EKG, chest x-ray, CT scan, sonogram, etc.
13. Labs:
    1. Blood tests, urinalysis, etc.
    2. These can be one-time orders for admission lab work or can be standing orders for continuous monitoring, for example, daily CBC.

Commonly Used Abbreviations

• AAA – abdominal aortic aneurysm
• abd – abdomen
• ABG’s – arterial blood gases
• a.c. – before meals
• ACBE – air contrast barium enema
• ACE – angiotension-converting enzyme
• Accuο – finger glucose monitoring
• ADA – American Diabetes Association (refers to diabetic diet)
• ADL’s – activities of daily living
• ad lib – as desired
• AF – atrial fibrillation, ≠ afebrile
• AFB – acid fast bacilli
• AKA – above the knee amputation
• AMA – American Medical Association
• AP – anterior-posterior
• AS/AI – aortic stenosis/aortic insufficiency
• ASHD/ASCVD – atherosclerotic heart disease/cardiovascular disease
• ASA – acetylsalicylic acid; aspirin
• ASAP – as soon as possible
• BaE, BE – barium enema
• BBB – bundle branch block
• b.i.d. – twice daily
• BKA – below the knee amputation
• BM – bowel movement
• BMP – basic metabolic panel
• BP – blood pressure
• BPH – benign prostatic hypertrophy
• BR – bed rest
• BRP – bathroom privileges
• B.S. – bowel sounds (+ or -) can also mean breath sounds or blood sugar as well as in expletive.
• BSO – bilateral salpingo-oophorectomy
• BUN – blood urea nitrogen
• BUS – Bartholin’s gland, urethra, Skene’s
• Bx – biopsy
• c – with
• c/o – complains of
• CA – cancer
• CABG – pronounced “cabbage” – coronary artery bypass graft
• CABG x_ – coronary artery bypass graft times number of vessels bypassed
• CAD – coronary artery disease
• CBC – complete blood count
• CC – chief complaint
• CHF – congestive heart failure
• CMP – comprehensive metabolic panel
• CN – cranial nerves
• CPE – complete physical exam
• CPK – creatinine phosphokinase
• CRF – chronic renal failure
• C & S – culture and sensitivity
• CSF – cerebrospinal fluid
• CT – computed tomography
• CVP – central venous failure
• C.X.R. – chest X-ray
• CMP – comprehensive metabolic panel
• D/C – discontinue or discharge
• DD – dependent drainage
• DDX – differential diagnosis
• Dx – diagnosis
• D5NS – 5% dextrose in 0.9% saline (W = water, LR = lactated ringers)
• DJD – degenerative joint disease
• DKA – diabetic ketoacidosis
• DNR – do not resuscitate
• DM – diabetes mellitus
• DOE – dyspnea on exertion
• DTR – deep tendon reflexes
• EBL – estimated blood loss
• EDD – estimated due date
• EGD – esophagogastroduodenoscopy
• EMD – electro-mechanical dissociation
• EOMI – extraocular muscles intact
• ETOH – ethanol
• ESR – erythrocyte sedimentation rate
• FB – foreign body
• FBS – fasting blood sugar
• FFP – fresh frozen plasma
• FiO2 – inspired oxygen tension, expressed a %
• FMHx – family history
• FR – french (a catheter size)
• FROM – full range of motion
• f/s/c – fever/sweats/chills
• Fx – fracture
• G – gallop
• GB – gallbladder
• G_P_A_ G = gravida, # of time pregnant
• P = Paral # of viable infants
• A = Aborted (s = spontaneous, t=therapeutic)
• GSW – gunshot wound
• gtt – drops
• GTT – glucose tolerance test
• HA – headache
• HCTZ – hydrochlorothiazide
• H/H or H and H – hemoglobin (hgb) and hematocrit (HCT)
• HEENT – head, eyes, ears, nose, and throat
• HJR – hepatojugular reflux
• HOB – head of bed
• H&P – history & physical
• HPI – history of present illness
• HR – heart rate
• h.s. – bedtime
• HSM – hepatosplenomegaly
• HTN – hypertension
• Hx – history
• I & D – incision and drainage
• I & O – intake and output
• IDDM – insulin dependent diabetes mellitus
• ICU – intensive care unit
• IM/IV – intramuscular/intravenous
• IVDU – intravenous drug use
• IVP – intravenous pyelogram
• JVD – jugular venous distention
• JVP – jugular venous pulse
• KUB – kidneys-ureters-bladder
• KVO – keep vein open (TKO = to keep open) specifies minimal IV fluid
• LAF – low animal fat
• LBBB – left bundle branch block
• LBP – low back pain
• L.E. – lower extremity
• LFT – liver function test
• LLQ/LLDq – lower left quadrant/left lateral dequbitus
• LLSB – lower left sternal border
• LMD – local medical doctor
• LMP/LNMP – last menstrual period./last normal menstrual period
• LOC – level/loss of consciousness
• LOS – length of stay
• LP – lumbar puncture
• LVH – left ventricular hypertrophy
• M – murmur
• M & M – morbidity and mortality
• MI – myocardial infarction
• MOM – milk of magnesia
• MRI – magnetic resonance imaging
• MRSA – methicillin-resistant Staph aureus
• MS – morphine sulfate; mental status; mitral stenosis; multiple sclerosis. Medical student
• MSE – mental status exam
• MVA – motor vehicle accident
• NAD – no apparent stress
• NAS – no added salt
• NG – nasogastric
• NHP – nursing home placement
• NIDDM – non insulin dependent diabetes mellitus
• NKMA – no known medical allergies
• N.P.O. – nothing by mouth
• NKA or NKDA or NKMA – no known (drug or medical) allergies
• NSAID – nonsteriodal anti-inflammatory drug
• NSR – normal sinus rhythm
• NTG – nitroglycerin
• N/V – nausea and vomiting
• OBS – organic brain syndrome (dementia)
• OC – oral contraceptives (OPC) or BCP = birth control pills
• ORIF – open reduction, internal fixature
• OS/OD – left eye/right eye
• OTC – over the counter
• p – after
• P&A – percussion and auscultation
• PAC/PVC – premature atrial contraction/ventricular contraction
• PCN – penicillin
• pc/pp – after meals/post prandial
• PCW – pulmonary capillary wedge
• PE – physical exam
• PERRLA – pupils equally round to light and accommodation
• PFT – pulmonary function tests
• Plt – platelets
• PO/PR/PV – by mouth/by rectum/by vagina
• PMHx – past medical history
• PND – paroxysmal nocturnal dyspnea
• p.o. – orally
• PRBC – packed red blood cells
• p.r.n. – as needed
• PT/pt – physical therapy/patient
• PTCA – percutaneous transluminal coronary angioplasty (balloon)
• PUD – peptic ulcer disease
• PVD – peripheral vascular disease
• Px – physical
• q – every
• qAM – every morning
• qD – every day
• qhs – at every bed time
• qhc – at meals
• q.i.d. – four times a day
• q.o.d. – every other day
• QNS – quantity not sufficient (for analysis)
• R.A. – room air
• RR – respiratory rate
• RLE – right lower extremity
• RML – right middle lobe
• RRR – regular rate and rhythm
• r/o – rule out
• ROS – review of systems
• RT – respiratory therapy
• RTC – return to clinic
• RUQ – right upper quadrant
• Rx – prescription
• s – without
• SBE – self breast exam
• SBFT – small bowel follow-through
• SEM – systolic ejection murmur
• sig – labeled directions; signmoidoscopy
• SLR – straight leg raises
• SMAC – multichemistry blood test
• SMD – small for dates
• SOA – short/shortness of air
• s/p – status post
• SQ – subcutaneous
• ss – sliding scale (insulin doses)
• SS – social stresses
• STD – sexually transmitted disease
• STAT – emergently
• Sx – symptoms
• T – temperature
• TAH – total abdominal hysterectomy
• TCA – tricyclic antidepressant
• TCN – tetracycline
• t.i.d. – three times a day
• TPN – total parenteral nutrition
• TRA – to run at
• TURP – transurethral prostatectomy
• Tx – treatment
• UA – urinalysis
• U.E. – upper extremity
• UGI – upper GI Xray
• UGIB – upper gastrointestinal bleed
• U/O – urine output
• UTI – urinary tract infection
• VA – visual acuity; Veterans Administration
• VF – visual fields
• VIP – very inappropriate personality
• VS – vital signs
• VSS – vital signs stable
• WNWD – well nourished, well developed
• WBC – white blood cells
• WM – white male
• WNL – within normal limits
• x – except